健康诊断书

健康診断書

CERTIFICATE OF HEALTH (to be completed by the examining physician)

日本語又は英語により明瞭に記載すること。

Please fill out (PRINT/TYPE) in Japanese or English.

氏名□男Male 生年月日年齢Name: , □女Female Date of Birth:Age: Family name, First name Middle name

１．身体検査

Physical Examination

(1) 身長体重

Height cm Weight kg

(2) 血圧血液型

脈拍□整regular Blood pressure mm/Hg～mm/Hg Pulse□不整irregular

(3) 視力

Eyesight: (R) (L)(R) (L)色覚異常の有無□正常normal 裸眼Without glasses矯正With glasses or contact lenses Color blindness □異常impaired

(4) 聴力□正常normal 言語□正常normal

Hearing: □低下impaired Speech: □異常impaired

２．申請者の胸部について，聴診とＸ線検査の結果を記入してください。Ｘ線検査の日付も記入すること（６ヶ月以上前の検査は無効?) Please describe the results of physical and X-ray examinations of the applicant's chest x-rays (X-rays taken more than 6 months prior

to this certification are NOT valid).

肺□正常normal 心臓□正常normal

Lungs:□異常impaired Cardiomegaly: □異常impaired

↓

←Date 異常がある場合

Film No. 心電図Electrocardiograph :□正常normal

□異常impaired Describe the condition of applicant's lungs.

３．現在治療中の病気□Yes (Conditions/particulars: ) Under medical treatment at present □No

４．既往症

Past history : Please indicate with ＋or －and fill in the date of recovery

Tuberculosis......□( . . ) Malaria.......□( . . ) Other communicable disease......□( . . )

Epilepsy......□( . . ) Kidney disease.....□( . . ) Heart disease......□( . . )

Diabetes......□( . . ) Drug allergy......□( . . ) Psychosis.....□( . . )

Functional disorder in extremities......□( . . )

５．検査Laboratory tests

検尿Urinalysis: glucose ( ), protein ( ), occult blood ( )

赤沈ESR:mm/Hr, WBC count:/cmm 貧血□

anemia

Hemoglobin:gm/dl, GPT:

６．志願者の既往歴，診察?検査の結果から判断して，現在の健康の状況は充分に留学に耐えうるものと思われますか？Yes又はNoにチェックをしてください。

In view of the applicant's history and the above findings, is it your observation that his/her health status is adequate to pursue st udies in Japan ?

Yes □No □

７．特記すべき事項

Particulars or additional comments:

日付署名

Date: Signature:

医師氏名

Physician's Name (Print):

検査施設名

Office/Institution:

所在地

Address: